Members of the Center for Palliative Care began our Research Program in 2010. Our research aligns with our MISSION to relieve the suffering of, and improve the quality of life for, patients with advanced disease and their families through compassionate, high-quality care, while advancing the field of palliative care through innovation, education and research. Our research program is focused on the following objectives:
Patients with advanced cancer experience a myriad of symptoms such as pain, depression, and insomnia. Research indicates that many of these symptoms tend to co-occur, forming symptom clusters. However, research and treatment continues to focus on individual symptoms with limited attention to the interrelationship of these symptoms. The most distressing symptom cluster reported by our patients is anxiety-insomnia-depression-pain-fatigue. Evidence suggests that this symptom cluster may be tied to a series of bio-behavioral mechanisms that develop over time including anxiety-induced elevations in cortisol and pro-inflammatory cytokines and insomnia-related changes in diurnal cortisol rhythms and consequent inflammatory dysregulation. These processes result in a symptom cascade that is not well-controlled by innate endocrine and immune mechanisms.
Few studies have systematically evaluated interventions for symptom clusters for this population of patients, particularly patients with more advanced disease. Although many proposed symptom cluster interventions are pharmacologic, cognitive behavioral therapy (CBT) is a well-established treatment for generalized anxiety, insomnia, depression, fatigue, and pain. Randomized trials of CBT for these symptoms report moderate to large effect sizes and many report long-term maintenance of treatment effects. Dr. Wells-Di Gregorio, Assistant Professor of Psychiatry and Clinical Psychologist for the Center for Palliative Care has developed a clinical trial utilizing cognitive-behavioral strategies for treating anxiety and insomnia. We anticipate that by treating anxiety and insomnia with CBT, the other symptoms in this cluster will also be reduced. We currently have a randomized trial underway to evaluate this CBT iIntervention and characterize the biobehavioral mechanisms underlying this symptom cluster. If the intervention demonstrates positive effects, we plan to expand this intervention to other populations of seriously ill patients (e.g. congestive heart failure, COPD, HIV, etc.).
Patient and families faced with the need for intensive care experience significant distress. A growing body of literature supports the importance of good communication in the intensive care unit (ICU) and a need for improved communication training. Pulmonary/critical care fellows are required to show competency in communication skills. Unfortunately, there are few published materials on fellowship curricula or methods of assessment to address communication as a core skill of critical care education.
Dr. Jillian Gustin, CPC Physician and Director of the Hospice & Palliative Medicine Fellowship research focuses on operationalizing the components of shared decision-making in the ICU as well as methods for teaching and assessing these important communication skills. We have examined the literature on communication in ICU settings and written manuscripts that broadly discuss the components of effective patient/family-centered communication. We have used our knowledge of the literature as well as educational theory to develop and implement a communication curriculum for Pulmonary/Critical Care fellows. As part of the curriculum, we have created and are validating an assessment tool that can be used for both formative and summative feedback. Our next step is to use this instrument with families as i) educational feedback for fellows, and as ii) a means to assess the communication strategies that are most helpful to family members with a loved one in the ICU.
Many medical, nursing, pharmacy and psychological programs are now beginning to provide more comprehensive pain management education to their students. This is a significant advance given that, historically, educational programs across all healthcare disciplines have included limited pain management training. Although this effort is encouraging, pain management is unlikely to improve in most institutions until key instructors such as attendings, preceptors, and supervisors are themselves equipped with adequate pain education. Ultimately, the preceptors’ decisions, uncertainty, and attitudinal barriers will determine whether students are able to learn about and implement effective pain management plans. The goal of this project is to improve pain management by 1) supporting preceptors through the creation and dissemination of a pain management development program for preceptors and 2) equipping preceptors to integrate standardized pain management teaching into clinical rotations.
Dr. Amber Hartman, Speciality Practice Pharmacist for the Center for Palliative Care has led an interdisciplinary team of pain management experts from the Wexner Medical Center in developing a didactic program designed to improve the fundamental pain management knowledge of preceptors. Our proposed project, Equipping Preceptors: A Practical Approach to Improving Pain Education,” will transition this didactic program to an interdisciplinary, interactive, e-learning environment with enhanced content. We have coordinated with the College of Medicine, the College of Nursing, the College of Pharmacy to study the impact of this teaching resource with an interdisciplinary group of preceptors including physicians, nurses, psychologists and pharmacists. The primary outcomes will be change in preceptor and student pain management knowledge, skills, self-efficacy and attitudes.
Individuals living with cancer experience many psychological, physical, social and spiritual challenges throughout their disease journey. Unaddressed, these challenges can disrupt cancer treatment and negatively impact survival. In order to promote screening and targeted distress interventions, distress screening has become a required standard of the American College of Surgeons Commission on Cancer Accreditation. That National Comprehensive Cancer Network has also published Distress Management Guidelines. According to these guidelines, the standard of care is regular screening of the level and nature of distress as well as management of distress according to clinical practice guidelines. One of the primary challenges in implementation of these standards is the selection of an instrument that is brief, but comprehensive enough to capture the most distressing needs of cancer survivors to facilitate triage to psychosocial, spiritual, and palliative care providers.
Drs. Sharla Wells-Di Gregorio and Emily Porensky, in collaboration with a team of supportive care providers and James Cancer Hospital Administration, have developed the 45-item Supportive Care Screening including six domains: (1) Emotional Concerns, (2) Physical Symptoms, (3) Social/Practical Problems, (4) Spiritual Problems, (5) Cognitive Concerns, and (6) Health Care Decision-Making/Communication Issues. This measure is designed for use by Cancer Centers implementing distress management processes in their own institutions. The next phase of this research involves translating this measure to an electronic format to be utilized in several ambulatory oncology clinics in order to evaluate the utility of this measure for triage, referral, and outcomes assessment.